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Vet suggesting euthanasia, any suggestions welcome...

I am not the owner of the horse in question, but I am desperate to find comfort for her. She has been laminitic, almost constantly, for a year and a half, with only a few months of comfort thrown in that time frame.

I am her hoofcare provider, and I go out every 2 weeks. I will give as much information as possible that I know. I have asked the owner to join ECIR and do a case history, but she hasn't, and I don't think she will. I will do my best with information but I understand if you can't help without a case history//in this kind of format.

The horse is question is a 9 year old foundered mini. She foundered in December 2018 after galloping around on frozen ground (per the owner.. I didn't meet her until April 2019). To our knowledge, she had not been laminitic prior, but could have been in a previous home.

She is overweight, and insulin is sky high.

Here are things the owner has done:

*She is on tested hay (ESC+Starch less than 10% each time, starch less than 2% each time. Iron is high but within balancing abilities). Even though the hay is tested, the owner still soaks it. *She is on a dry lot during the day IF she is even outside. If she is inside, she has free access to her dry lot run out and can move at will. *She is fed KIS Trace on top of timothy grass pellets. I forget the brand, but the owner has contacted the company for the analysis. It is not Standlee, but an "organic" brand. The copper and zinc levels in KIS balance the hay test fine. Owner is concerned about "sulfates" but we are trying to get her to stop the KIS for now just to start at a baseline. She is hesitant.

*Vet has trialed her on metformin, Thyro-L, and metacarbol (I think that's what it's called, the resveratrol supplement). None had much of an effect. Insulin still sky high and she is still overweight and uncomfortable. *ACTH levels were 13 at the last test. Insulin over 200. *Iron bloodwork: Her TSI is 36%, ferritin is 298, per KSU Iron assay. *She is sore even in boots and pads and on deep shavings. Ground surface doesn't make a difference in comfort. *No heat or pulse in her feet for months.

Vet and I get together and trim to radiographs. That being said, her palmar angle is high BECAUSE If I trim her heel, she stands on her toe and buckles over even more at the knee, maybe a "cringe" effect or her tendons just can't take lowering the heel? She is marginally more comfortable if I leave more heel.

*Banamine eases the pain a LITTLE but not significantly. We use banamine occasionally for trims but not always.

Here are some links to radiographs and hoof photos. I have tons more rads but don't want to post them on my instagram, and don't have a case history for her... :

It sounds as if you’ve been doing a lot over quite some time to try and help this little pony. Would there be any chance that the owner might sign her over to someone who understands the ECIR protocol, if there’s anyone appropriate in the area and also in a position to take her on?

Nice job on the trim, Alicia. Has she ever abscessed? Is the P3 bone density decreasing? I hope she's not still on Banamine. That could be part of the problem.

You have a chronic pain situation which may have a component of neuropathic pain. The uncontrolled insulin is probably at least partially driven by the pain but I wonder if it has ever been controlled.

If they are willing to give another approach a try, a one month trial should be more than sufficient to see if it will work. She's a candidate for Invokana for insulin control. I have a file for vets on this. Need to screen renal function and absolutely stop the Banamine.

Instead of Banamine which doesn't work anyway, I would get her on Jiaogulan, acetyl-L-carnitine and Vitex agnus-castus for its opioid effect. Could also try capsaicin cream on the back of her pasterns four times a day to try to interrupt the pain signals to some extent which might help those flexor muscles relax.

Hi Alicia,I’m glad Dr. Kellon saw this and responded. I had a similar situation with a small pony. She had a mild laminitis attack after eating some March ‘grass’ many years ago. I did not know about the ECIR group at the time but my vet started me soaking her hay and she was on metformin for much longer than it was likely to be effective. For the most part she was fine. Then, some years later, she was off again, although I had changed nothing, even soaking hay that tested fine. Of course, we (vet included) assumed It was laminitis again, although it was unclear whether there was rotation. This situation lasted at least a year. Then, with more opinions coming forth that were not prejudiced by her earlier history, we began treating her as though she had navicular issues. Her sky high insulin came down and she has not been lame in the 4-5 years since. Of course, I continue to watch her diet and treat her like the IR pony she is.

I like the idea of using capsaicin. CBD is also good for neuropathic pain.--

If she's overweight, what is the owner doing to try to get her to more appropriate weight? Obviously she can't be exercised, but is her intake limited at all? Obviously the timothy pellets can be an issue since they're untested, but to start with I'd try to get her to a more appropriate diet for her ideal weight in addition to Dr. Kellon's suggestions.

FWIW, I sent a sample of KIS to Equi-analytical in April of 2019 to check ESC, starch and iron. Came back 3.0 ESC, 1.4 starch, and 1,770 ppm iron. I assume like other products there is no added iron, this is just from the process and ingredients. Maybe that works out to an acceptable iron amount in your case -this is solely an FYI.

OH my goodness, I can't believe 1770ppm of iron!! Is that true of Vermont Blend, California Trace, and the like?

Dr. Kellon - thank you for the response. Where can I access the document to send to the vet?

Her P3 has had demineralization over the last year :( I have not seen her abscess, although right before I met her the previous farrier opened up a blood/serum pocket by the toe which seemed to offer her some relief. We haven't seen anything like that again.

She grows a LOT of foot; I have to trim sole (!) each time with my half rounds or her feet build up like little coke cans.

She was on jiaogulan for a while with no effect, and I did tell the owner about ALCAR but not sure if she purchased it.

The vet is seemingly open to anything (he tested iron despite being skeptical that could have any correlation in any way). -- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

Her hay is in slow feed hay nets and soaked, I'm not sure how many pounds she feed per day, but it never seems like when I am there that she has an excessive amount (maybe a few pounds soaked, in a mostly empty hay net, is the mostly I've ever seen). -- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

I do believe the owner only gives banamine the day of and a few days after a trim, but I can confirm when I see her Monday! We aren't sure what else to do to get her to lift her feet for the trim-- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

Oh yes I totally agree, but we can't seem to find the source.. I keep telling her that we haven't found the trigger yet if she's still painful.

Vet hasn't tested for Lyme. I've asked him 3 times. He says there isn't much evidence that Lyme causes laminitic pain. He mentioned a few studies of why some think that but I was trimming and not totally focused on what he was saying. He doesn't think it would cause 1.5 years of pain. He isn't against testing for it, I'm hoping he does test this next trim on Monday.-- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

We have quite a few horses on the group which have persistently elevated insulins, even without pain to that extent. The condition seems to progressively worsen in some horses but fortunately they respond to either metformin or Invokana. There have been no Invokana failures, even in horses that did not respond to metformin.

The pathophysiology of the pain is complicated and not completely understood but neuropathic changes to the nerves has been documented (acetyl-l-carnitine for that) and so has greatly elevated levels of endothelin-1, a potent vasoconstrictor that is higher in chronic than acute cases. Jiaogulan addresses that.

The Lyme cases I have been involved with have much greater pain and hoof damage than you would predict from relatively small elevations in insulin but that could be a different story in a horse with EMS at baseline.-- Eleanor in PA

I'll bring up the Lyme stuff again, and I'll try to type up everything you mentioned as talking points when I see him Monday. I feel like I'm failing this mini which breaks my heart!-- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

I'm going to see this mini today and will chat about Invokana. Where can my vet access the file for it, or how can he reach out to you Dr. Kellon? -- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

Megan had a similar situation with high insulin and iron numbers and sensitive feet. I had tested the hay and balanced her diet, and it wasn't enough. The Jiaogulan was notably helpful at temps < 60 deg F, and the AlCar also seemed to really help. However, the thing that finally started turning her around was shifting to a Tifton hay, with extremely low ESC + starch (<2% total, EA 601 test). I know the NDF is high, but the ADF < 40% and she eats it. She also gets a little alfalfa hay and morning bahia grass in the muzzle. She doesn't get any pelleted supplements; mainly balancer cubes and AZ Cu Complete. I think for Megan, she couldn't handle even low ESC + starch hay, it had to be super low. I haven't had her insulin tested recently, but the hoof lines haven't been as noticable and her fat pads and crest are down by 50-75%, and I have finally started riding her again. I need to update her case study again. I hope you can find something to help your pony, too.-- Jackie and MeganPalm Bay, FLJoined March 2018

I don't think I have your email address? He's a bit wary of ECIR. He's big into peer reviewed research. He doesn't think the diet suggestions are unreasonable, though. He pulled blood today for Lyme, and insulin again. And we are stopping the KIS minerals after a friend's analysis came back at 1900ppm iron and only 800ppm zinc and like 100ppm copper!!! Way less than advertised. -- -Alicia Harlov in South Hamilton, MA PHCP hoofcare provider, The Humble Hoof podcast

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